1. Dysphagia Screening – State of the Art Conference Proceedings from the State of the Art Nursing Symposium International Stroke Conference 2012
Neila J. Donovan, PhD, CCC-SLP
Stephanie K Daniels, PhD, CCC-SLP, BRS-S
Jeff Edmiaston, MS, CCC-SLP
Jan Weinhardt, MSN, RN, GCNS-BC
Debbie Summers, RN, MSN, FAHA, ARNP
Pamela Mitchell, PhD, RN, FAAN, FAHA 1 1
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

2. The Clinical Dilemma
National Quality Forum (NQF) was unable to endorse dysphagia screening because there were no clinical trials completed that identified an optimal swallow screening.
Joint Commission retired the dysphagia screening performance standard due to the lack of a standardized screening tool.
There is concern that clinicians will omit dysphagia screening, leading to worse patient outcomes.
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3. Conference Purpose
Review characteristics of valid and reliable screening and assessment tools
Identify strengths and limitations of most commonly used current tools
Describe how to make decisions about dysphagia screening selection
Provide an example of institutional quality improvement in establishing swallow screening for stroke
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4. Background Stroke is a leading cause of dysphagia -- 42%
Aspiration occurs in 50% of dysphagic patients
1/3 develop pneumonia
Associated with three-fold higher mortality
To avoid aspiration, new stroke patients are left NPO until dysphagia screen: “no ice chips, no oral medications, no water, no exceptions!” (several guidelines)
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5. What is Needed: Reliable and Valid Screening Tools
Dysphagia screening - pass/fail procedure to identify an individual who may or may not need a complete dysphagia assessment
Can be performed by trained clinician
Contrasted with Swallowing Assessment – a behavioral evaluation of swallowing function that consists of an extensive cranial nerve evaluation and direct examination of swallowing
Performed by Speech-Language Pathologist (SLP) Instrumental dysphagia assessment aims to Identify swallowing impairment and the effects of compensatory strategies
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

6. Background
Research has shown that swallow screening by trained nurses and physicians is feasible and reliable.
Important predictors of dysphagia and risk of aspiration may include:
Abnormal volitional cough
Dysphonia
Dysarthria
Cough after swallow
Voice change after swallow
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7. Effective Screening Tool
Quick and minimally invasive with high sensitivity and specificity to identify dysphagia and aspiration risk
Defined scoring system
Pass – patient can be fed
Fail – patient kept NPO and speech language pathology consulted
Specifies level of training required for staff performing screening
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

8. Several Dysphagia Screenings are Available for Nurses to Administer in Acute Care
3-ounce water test (DePippo et al., 1992; Suiter & Leder, 2008)
Burke Dysphagia Screening Test (DePippo et al., 1994)
Toronto Bedside Swallowing Screening Test (Martino et al., 2009)
Bedside Swallowing Assessment (Smithard, 1997)
The Timed Test (Hinds, 1998)
Standardized Swallowing Assessment (Perry, 2001)
Gugging Swallow Screening (Trapl et al., 2007)
Acute Stroke Dysphagia Screening (Edmiaston et al., 2010
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9. Screening Tool Selection
No single screening tool is best for all contexts
Contextual elements
Organization structure
Patient flow and composition of heath care
Size of hospital, volume of stroke patients
Personnel – nursing and speech language pathology
Availability of radiology
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

10. Screening Tool Selection
Kepner Tregoe Decision Matrix (K-T Matrix) can be utilized to best determine a multidisciplinary teams’ needs when choosing a screening tool
Easily identifies important factors deemed most important
In context of personnel and training needs
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

11. Screening Tool Selection and Implementation
Conceptual Model: Each component is a sequential step in the process of organizing a clinical interdisciplinary team and CQI
Agree
Build
Commence
Document
Evaluate
Feedback
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12. CQI and Tool selection What? Select Screening tool
Consider evidence for reliability and validity
Consider ease of administration, time, safety for patient at risk- input from the staff nurse or designated nurse(s)
Consider resources available and tailor it to the specific institution
Remember, nurses do screens, SLPs do evaluations 12
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13. Evaluate for your context
Was the tool valid?
Was it easy, efficient, safe? Modifications?
Was there congruence between nurse and SLP?
Was there compliance in keeping patient NPO until screen completed?
Long term:
Aspiration pneumonia rate
Patient satisfaction
Physician satisfaction
Readmission, LOS, cost effectiveness
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.

14. Conclusions from Symposium
Screening of swallowing in stroke patients is critical, to prevent adverse outcomes related to aspiration and inadequate hydration/nutrition
Absence of consensus on best screening instrument does not mean no screening should be done
Use the American Speech Language Hearing Association (ASHA) definition: “Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services.”
©2013 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited.